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Infection Prevention and Control

A Foundation Course 2014

What is healthcare-associated infection (HCAI),

antimicrobial resistance (AMR) and multi-drug resistant organisms

(MDROs)?

Why we should be worried?

Dr. Deirdre O’Brien

Consultant Microbiologist

Mercy University Hospital and

South Infirmary Victoria University Hospital

Talk outline

•What is healthcare associated infection?

•Why is antimicrobial resistance such an important issue?

•Discussion of resistant bacteria (MRSA, VRE, ESBLs, CRE)

•What can be done?

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HCAI definitions

Nosocomial infection

•Develops 48 hours or more after admission to a hospital and not present or incubating on admission

Health care associated infection (HCAI)

•An infection acquired following a health care intervention e.g. hospital, outpatients, long term care facility/nursing home, GP surgery

Health care associated infection

•Patient may have received:

•Hospital care for 2 days in the previous 90 or be an inpatient

• received outpatient care e.g. haemodialysis in previous 30 days

•homecare e.g. wound care

• reside in a nursing home or long term care facility

HCAI definitions • May be classified by:

• Pathogen – bacterial, viral, fungal

• How it was acquired i.e. exogenous or endogenous

• By site of infection e.g. organ specific, device specific

• By resistance phenotype e.g.

• Meticillin resistant S. aureus (MRSA)

• Vancomycin resistant Enterococcus (VRE)

• Extended spectrum B-lactamase (ESBL) producing gram-negatives

• Carbapenem resistant Enterobacteriaceae (CRE)

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• Surgical site infection

• Inadequate prophylaxis

• Inadequate skin prep

• Inappropriate wound care

• Type of wound

• Poor surgical asepsis

• Underlying medical condition

• Diabetes, immunosuppression, malnutrition

• Urinary tract infection

– Urinary catheter

– Urinary invasive procedures

– Advanced age

– Urolithiasis

– Pregnancy

– Diabetes

• Lower respiratory tract infection

– Mechanical ventilation

– Aspiration

– Nasogastric tube

– Advanced age

– Surgery

– Underlying medical condition

• Diabetes, immunosuppression, malnutrition

• Blood stream infection

– Vascular catheter

– Neonates

– Critical care

– Severe underlying condition

– Immunocompromise e.g transplant, neutropenia

– New invasive techniques

Gastro-intestinal infection •Antibiotics •Proximity to known cases of CDI •Advanced age, PPIs, surgery

The impact of HCAI

• Increased mortality • Rate of 16-40% in critically ill patients with blood

stream Infection • Up to 30% mortality with S. aureus infection • Up to 70% mortality with CRE infection

• Increased morbidity

• Increased hospital length of stay • An average of 4 days per infection

• Increased costs

• Patient impact – suffering, pain, loss of income

• Increase in antimicrobial resistance and multi-drug resistant organisms

HCAI surveillance in Ireland

• National initiative - HPSC

• Development of guidelines, standards, agreed definitions for surveillance

• Prevalence surveys MRSA 1999 and HCAI 2006, nursing homes HALT 2010, 2011, 2013.

• Surveillance

• EARS-net and enhanced bloodstream infections

• Notifiable diseases including C. difficile

• HALT survey

• Antimicrobial use/alcohol gel use

• Surgical site infection surveillance

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What is the burden of HCAI in Ireland?

European Point Prevalence Survey 2012

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HALT-2 Point Prevalence Survey 2013

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Types of infection in LTCF

Why is antimicrobial resistance an issue?

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Antibacterial agents approved, 1983-2007

The chief medical officer, Dame Sally Davies, warns of a major increase in

the number of bugs resistant to antibiotics. In a report published on

Monday she says antibiotic-resistant bacteria with the potential to cause

untreatable infections pose 'a catastrophic threat' to the population ranked

alongside terrorism on a list of threats to the nation

March 11 2013

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Enterobacteriaceae

• Enterobacteriaceae family: E coli, Klebsiella spp, Enterobacter spp.

• Normal gut flora

• Common cause UTI in community

• Hospital acquired infections: UTI, pneumonia, intra-abdominal infections, wound infections, bloodstream infections

Carbapenems

• Carbapenems are invaluable for the treatment of infection due to multi-resistant Gram negative bacteria

• Meropenem, ertapenem, doripenem, imipenem

Treatment Options for CRE

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Multi-drug resistant organisms

•MRSA

•VRE

•Multi-resistant Gram negative bacteria (ESBLs, CRE)

•Penicillin resistant Streptococcus pneumoniae

• Extensively drug resistant TB

•Multi-drug resistant gonorrhoea…..

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What levels of antimicrobial resistance are present in Ireland? How do we compare to other countries?

EARS-net

• EU Surveillance network for antimicrobial resistance

• Key pathogens

• Began 1999

• Excellent participation by Irish laboratories

Distribution of MRSA in EARS-Net countries in 2009

Map downloaded from:

http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/Pages/Database.aspx

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MRSA 2011

MRSA 2012

VRE 2010

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VRE 2012

Carbapenem resistant Klebsiella pneumoniae 2011

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2012…

What can be done?

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• Awareness and communication

• Antimicrobial stewardship

• Infection prevention and control

How can the spread of MDROs and HCAI be prevented?

SENIC study

Appropriate infection control input resulted in a:

• 32% reduction in overall HCAI

• 27% reduction in Lower Respiratory Tract Infection

• 35% reduction in Surgical Site Infection

• 35% reduction in Blood Stream Infection

• 31% reduction in Urinary Tract Infection

•Haley RW et al Am J Epidemiol 1985

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• A more recent review found a minimum reduction effect of 10% to a maximum of 70%

• It is accepted that on average 20–30% of all nosocomial infections can be prevented

• An even larger proportion (>50%) of device-associated bloodstream infections can be prevented • in catheter-related bloodstream infections can range from 29% to 95%

• In case of ventilator-associated pneumonia, studies suggest that average reductions of more than 40 % are possible

J Hosp Infect. 2003:54;258-266.

J Hosp Infect. 2006;64:326-335.

J Hosp Infect. 2006;64:326-335.

• Nationwide spread of CRE in Israel 2006- failure to contain a local levels

• Acquisition rate of 55.5 cases per 100,000 patient days

• National intervention for CRE containment

Acquisition rate now 4.8 cases per 100,000 patient days..

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What worked?

Local strategies we can all do*

• Hand hygiene audits

• Environmental cleaning and audits

• Central line surveillance

• Ventilator associated pneumonia surveillance

• Surgical Site Infection surveillance

• Catheter associated UTI surveillance

• Local monitoring of MRDOs

• Implementation of care bundles and guidelines…

……Feedback above results to local teams

*but might need more resources

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What about antimicrobial use?

Antimicrobial use in Europe

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Take home messages

• HCAI and MDRO a significant burden in Irish healthcare

• Antimicrobial resistance a real threat to how we all practice medicine

• Stewardship and adherence to infection prevention and control practices our best (only) means to limit the spread

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Thank you!

Questions…….